GW1-2022-09109_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 25 ft. 40 ft. Wet
2973
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER TH ICKNE55 MATERIAI,
Parratt-Wolff, Inc. ft. ft. i in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 20 ft. 4 in. sch40 pvc
List all applic•ahle urell permas(i.e.Cauniv.Slate,Variance,Injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft' 40 ft. 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 16 ft- Portland Cem Tremie
Non-Water Supply Well:
OMoni[oring ❑Recovery
16 rt. 18 rr. Bentonite Chii Tremie
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK,tf a licable
FROM TO MATERIAL EMPLACEMENI'METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18 ft' 40 rr• #1-Sand Tremie
El Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG;attach additionlil sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,suilhnck type,grain size,etc.
❑Creothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Dare Well(s)Completed: 7-19-22 Well ID# MW-99
Sa.Well Location:
Colonial Pipeline Company fr. ft. — _
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
14511 Huntersville-Concord Road, Huntersville, NC 28078
ft. ft. R ._,•fit':'.
Physical Address,City,and Zip -
21.REMARKS
Mecklenburg 4"Pro Cover
County Parcel Identification No.(PIN) 2 x2 pad
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
35.412447 N -80.807597 N
Signature of'Cenified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
HV signing Ibis/n oo,/hereby cerli/} that Ire well(sj uus +sere constructed in accordance
with 15A NCAC 02C.Ill00 or 15A N'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or El No copy of this record has been provided to the iveit o-ner.
I/'this is a repair,Jill out known well construction iglbrnralion and explain the nature q/7he
repair cooler=21 remarks section or on the hack n/'this jornr. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
har multiple injection or non-+raler supply wells ONLY+rich the sane construction,you can
submit one juror. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 40 24a. For All Wells: Submit this!form within 30 days of completion of well
l•br tom/lip/e trel/s list al/deplas t/'dt/lerent(example-3@200'and 2 /00') construction to the following:
10.Static water level below top of casing: 25 (ft•) Division of Water Resources,Information Processing Unit,
I/'traler level is above casing use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: ;In addition to sending the form to the address in
4 1/4 HSA & 2" spoons 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I.
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection`Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: Amount: well construction to the county heAlth department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013